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FROM THE ARCHIVES:
February 26, 2003
Why Emergency Rooms Rarely Test Trauma Patients for Alcohol, Drugs
Alcohol-related accidents and mishaps left Alan Levine with two amputated feet, a broken back, a ruptured spleen and only four remaining teeth.
Yet in 10 visits to emergency rooms in California, Nevada, Oregon and Washington, he says he was never tested for alcohol in his blood, nor was he ever urged to get counseling. "None of the so-called professionals mentioned treatment or counseling or gave any indication there was something wrong," says Mr. Levine, 57 years old, who stopped drinking several years ago and now volunteers as a substance-abuse counselor in Portland, Ore.
In fact, most of the nation's emergency rooms and trauma centers don't routinely run blood-alcohol tests or "tox screens" on patients thought to be intoxicated. Why? At trauma centers, which treat the most seriously injured patients, the first priority is generally to save lives and provide immediate care. But doctors say another big reason the tests aren't performed is the obscure, decades-old laws adopted in 38 states and the District of Columbia that give insurers the option to deny medical reimbursements to patients under the influence of alcohol or narcotics.
Aware that health-insurance policies can contain this exclusion, hospital staff seldom run the tests or urge counseling, for fear the results will appear in claims records and reimbursements will be denied. "Doctors don't test because they're afraid they won't get paid," says Larry Gentilello, the 49-year-old chief of trauma and surgical critical care at Boston's Beth Israel Deaconess Hospital.
Dr. Gentilello has been waging a grinding, three-year fight with insurers, regulators and state lawmakers to repeal the laws and make drug and alcohol tests and counseling a routine part of trauma care. He has the support of groups including Mothers Against Drunk Driving, the National Highway Traffic Safety Administration, the National Association of Insurance Commissioners and the American Society of Addiction Medicine, but progress has been slow. Maryland, North Carolina and Vermont have repealed their laws, but repeal efforts have failed in legislatures in New York, Washington and Arizona.
A three-time college dropout, Dr. Gentilello grew up in New York's Washington Heights, drove a Checker cab and worked at a White Hen Pantry convenience store before applying to medical school. During his surgery residency at the University of Texas Health Science Center in Houston, he began to wonder why trauma care for substance abusers wasn't automatically linked to counseling.
In a three-year, federally funded study published in the Annals of Surgery in 1999, Dr. Gentilello looked at more than 700 trauma patients admitted to Seattle's Harborview Medical Center for alcohol-related injuries. The patient group that received 30 minutes of counseling at the hospital experienced a 47% reduction in serious injuries requiring trauma-center admission in the following three years, plus a 48% reduction in less-serious injuries requiring ER care.
With alcohol and drug-related injuries accounting for as much as half of all trauma-center visits, such reductions on a national scale could save as much as several billion dollars a year in health-care spending, Dr. Gentilello figures. But eager to cut costs, insurers are denying alcohol and drug-related claims more often, he believes.
Dr. Gentilello says insurers' denial of coverage to substance abusers is short-sighted and discriminatory. "Do we not treat venereal disease if the person did not wear a condom? Do we not treat emphysema in a patient who will not stop smoking?" he asks.
Jeffrey Hammond, chief of trauma and surgical critical care at Robert Wood Johnson University Hospital, New Brunswick, N.J., says doctors' awareness of denied reimbursements has led to a steady decline in testing and counseling during the past five years. Ideally, most adults admitted to trauma centers would be tested and referred to counseling when appropriate, he says. But without the assurance of payment, many hospitals and doctors can't afford to jeopardize profits by providing such preventive care. "No margin, no mission," Dr. Hammond says.
Philip Barie, director of the surgical intensive-care unit at New York-Presbyterian Hospital in Manhattan, says he routinely avoids testing patients' blood alcohol because he doesn't want to risk having their insurance claims denied. Once a blood-alcohol test is completed, "it's in the record and they have grounds to deny the claim," Dr. Barie says. "Hospitals are not in business to lose money, and doctors depend on the billings."
Insurers say they can't afford to cover everything, and the cost of claims would go up, not down, if they had to cover all the injuries of people under the influence of alcohol and drugs. But beyond economics, they say, there's an ethical concern: Medical needs, not insurance coverage, should drive health-care decisions.
"Quite frankly, I'm a little disheartened that physicians would base their treatment decisions on whether or not they might be reimbursed by an insurance policy," says Larry Akey, spokesman for the Health Insurers Association of America, a 300-member trade group. The HIAA has argued that doctors who won't order tests and counseling for alcoholics and drug abusers because of financial concerns are guilty of a "shocking abdication of responsibility." Trauma doctors don't need permission to test for drugs or alcohol while treating their patients.
The state insurance laws at issue are based on the Uniform Individual Accident and Sickness Policy Provision Law, or UPPL, a model law drafted by state insurance commissioners in 1947. The HIAA's Mr. Akey says a number of the group's members have such provisions in their policies but wouldn't identify which companies. Aetna Inc. and Cigna Corp., two of the nation's largest health insurers, say they don't have such provisions.
But Dr. Gentilello says Cigna recently denied a trauma-care claim at Boston's Beth Israel because the patient was intoxicated. He says the hospital fought the denial, and eventually Cigna paid. A Cigna spokeswoman says the company can't comment without the patient's name; Dr. Gentilello says he can't name the patient due to confidentiality rules.
Deana Watterson, a 44-year-old waitress in Mouton Cove, La., suffered a ruptured duodenum and other internal injuries in a 1997 car accident. Because there was alcohol in her blood, she says, her insurer didn't cover the nearly $200,000 cost of her treatment at Our Lady of Lourdes hospital, in Lafayette. She filed for personal bankruptcy; the hospital wrote off the costs. The lesson? "Given the option, I don't order blood-alcohol tests," says Christopher Lee, the surgeon who treated her. "And I ask the ER docs not to order them."
Write to Rachel Zimmerman at email@example.com
Updated February 26, 2003
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